Provider Demographics
NPI:1346653052
Name:ADVANCED SPINE AND PAIN CLINICS OF MN, LLC
Entity Type:Organization
Organization Name:ADVANCED SPINE AND PAIN CLINICS OF MN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:G
Authorized Official - Last Name:THORSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:612-207-7463
Mailing Address - Street 1:7373 FRANCE AVE
Mailing Address - Street 2:SUITE 606
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-4552
Mailing Address - Country:US
Mailing Address - Phone:612-207-7463
Mailing Address - Fax:952-831-0276
Practice Address - Street 1:308 BRIGHTON AVE
Practice Address - Street 2:SUITE D
Practice Address - City:BUFFALO
Practice Address - State:MN
Practice Address - Zip Code:55313-2303
Practice Address - Country:US
Practice Address - Phone:763-595-1411
Practice Address - Fax:763-595-1412
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADVANCED SPINE AND PAIN CLINICS OF MINNESOTA, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-06-10
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site